I've been working on wedding preparations these two nights off. Night is a great time to work. There's no distractions: like a television, and the cats don't play with all the ribbons and things I am using for the various projects I need to complete and ship within the next three weeks.
I've avoided blogging about my wedding on this site mostly because I wanted to keep it focused on Emergency Medicine and my residency training experiences. I have a bunch of pictures, etc. on my Facebook.com site. So, if you have an account, you can check me out there...
However, the last two days I've thought back to my college days and some issues I had during my sorority initiation. Mostly, I was always late to meetings. They didn't have any repercussions for being late, and I was usually only about 5 - 10 minutes late. But, they got me back during Initiation Weekend. As my punishment, I had to wear every house member's watch (somewhere around 15) and before I was allowed to speak I had to say, "I'm late, I'm late, for a very important date, no time to say hello, good-bye, I'm late, I'm late, I'm late." And then give the current time. (For all you Greeks out there aghast that I am spilling initiation secrets loosen the sphinctone. I graduated from college almost 20 years ago, and I doubt anyone in the house (SigThX) is going to come after me.)
That's kind of how I feel right now. I have so much to do, and I feel like I am running quickly out of time. By the way, my wedding is on the OTHER side of the country, so everything has to be done about a week before I leave so I can ship it. I am still trying to figure out how to carry my dress, which is "poofier" than I remembered, onto the plane. Any suggestions?
Ok. That's about it right now. I am on vampire time, but need to get some kind of nap in since we have meetings in the morning as it's Grand Round Wednesday. Then I go back to work for my last 3 shifts of this rotation. Free weekend coming up. Superbowl Sunday. Sigh, I have so much to do...
Tuesday, January 29, 2008
Monday, January 28, 2008
E.D. Rollercoaster Ride
One day you're rushing around like crazy, getting slammed on all sides, and the next night you're sitting around discussing the death of Princess Diana, hypothetical situations necessitating "opening and packing" trauma patients, socialist medicine, and Latin phrases. Of course, the first one most physicians learn is "Primum non nocerum" - First do no harm.
In our case, my attending gave me several Post-it notes with the letters "FOS" on them. Usually, FOS means "Full of S*&#" most often referring to a CT scan or abdominal x-ray showing copious amounts of, well, S*&#. But, in this case, my attending was referring to himself being, "Full of Science." He gave them to me with the understanding that I could stick one to his white coat if I felt he was giving me too much information from the medical literature which had nothing to do with the current patient's condition. It's a medical/science thing so maybe not funny to you, but seriously laugh a minute to us.
As you can guess, the patient load was low. I think the first 3 patients I saw, I went in, evaluated them, determined there was really nothing to do with them, and we sent them on their way with reassurance that they were fine and needed nothing further. My fourth patient had a migraine, so I gave them some medication, they felt better, and off they went. My next 2 patients kept me busy with labs and such until about 3 in the morning when there were no more patients waiting, and my attending said I could leave. So I did.
I had that evening free and this evening free. In case you're paying attention to the time, this is now Tuesday morning. Because I am trying to keep my Vampire hours and my internal clock set appropriately, I am keeping myself awake for as long as I can. Then I'll take a "nap" for several hours before doing this all over again. I go back to work on Wednesday night for the next three nights, and then, believe it or not, I am done with this rotation. My next is anesthesia which will be sort of like the free for all that ultrasound was except with needles and breathing tubes.
Since the two more complicated patients were rather boring, I won't bore you with their details. Suffice it to say that sometimes I miss working at a place like Brigham and Women's in Boston. I miss havingthe ability to perform whatever procedure is deemed necessary. The challenge of rural medicine is making due with what you have and being able to stabilize patients given your resources. Which is where the conversation about "opening and packing" came in.
Princess Diana officially died of a tear in her pulmonary vein leading to her bleeding out into her chest. Had she been in the U.S. her likelihood of survival would have been higher given that EMS units here follow the edict of "Scoop and Run." Serious patients aren't managed in the field, they are brought to a hospital for more definitive care. Not so in France. They try to stabilize in the field. According to official reports, it took almost 2 hours for her to be brought in to the hospital because the ambulance crew first tried to stabilize her in the field and then actually stopped en route to the hospital when her blood pressure fell.
My discussion with my attending had to do with "cracking the chest" and then trying to temporarily repair the damage so that the patient would survive transport to ECMC which is the closest major trauma center. In trauma surgery sometimes you open a patient with massive bleeding and just pack everything off and then go back in later when you have the patient more stable. It's called "Damage Control" surgery. You just hope to get the patient through the physiological processes that happen after major trauma so that they can survive the surgery that will actually repair the physical damage.
So too in the rural E.D. setting. I guess you can think about it like a M*A*S*H setting. You don't do anything fancy. That comes later. Keeping the patient alive long enough to be ultimately repaired is the goal. Anyway, we had a lively discussion of scenarios and possible means of repair. He had a lot of war stories to tell, and I can appreciate the need to work within your abilities and resources.
As for my cancer patient from the day before, they pulled out 550 cc of fluid from her lung, and it looked much improved on chest x-ray today. If you remember the bottles from some of my prior entries, it would be a 1/2 liter; about the amount of one of those bottles. She still has some fluid there and will probably need that tapped at some later time.
In our case, my attending gave me several Post-it notes with the letters "FOS" on them. Usually, FOS means "Full of S*&#" most often referring to a CT scan or abdominal x-ray showing copious amounts of, well, S*&#. But, in this case, my attending was referring to himself being, "Full of Science." He gave them to me with the understanding that I could stick one to his white coat if I felt he was giving me too much information from the medical literature which had nothing to do with the current patient's condition. It's a medical/science thing so maybe not funny to you, but seriously laugh a minute to us.
As you can guess, the patient load was low. I think the first 3 patients I saw, I went in, evaluated them, determined there was really nothing to do with them, and we sent them on their way with reassurance that they were fine and needed nothing further. My fourth patient had a migraine, so I gave them some medication, they felt better, and off they went. My next 2 patients kept me busy with labs and such until about 3 in the morning when there were no more patients waiting, and my attending said I could leave. So I did.
I had that evening free and this evening free. In case you're paying attention to the time, this is now Tuesday morning. Because I am trying to keep my Vampire hours and my internal clock set appropriately, I am keeping myself awake for as long as I can. Then I'll take a "nap" for several hours before doing this all over again. I go back to work on Wednesday night for the next three nights, and then, believe it or not, I am done with this rotation. My next is anesthesia which will be sort of like the free for all that ultrasound was except with needles and breathing tubes.
Since the two more complicated patients were rather boring, I won't bore you with their details. Suffice it to say that sometimes I miss working at a place like Brigham and Women's in Boston. I miss havingthe ability to perform whatever procedure is deemed necessary. The challenge of rural medicine is making due with what you have and being able to stabilize patients given your resources. Which is where the conversation about "opening and packing" came in.
Princess Diana officially died of a tear in her pulmonary vein leading to her bleeding out into her chest. Had she been in the U.S. her likelihood of survival would have been higher given that EMS units here follow the edict of "Scoop and Run." Serious patients aren't managed in the field, they are brought to a hospital for more definitive care. Not so in France. They try to stabilize in the field. According to official reports, it took almost 2 hours for her to be brought in to the hospital because the ambulance crew first tried to stabilize her in the field and then actually stopped en route to the hospital when her blood pressure fell.
My discussion with my attending had to do with "cracking the chest" and then trying to temporarily repair the damage so that the patient would survive transport to ECMC which is the closest major trauma center. In trauma surgery sometimes you open a patient with massive bleeding and just pack everything off and then go back in later when you have the patient more stable. It's called "Damage Control" surgery. You just hope to get the patient through the physiological processes that happen after major trauma so that they can survive the surgery that will actually repair the physical damage.
So too in the rural E.D. setting. I guess you can think about it like a M*A*S*H setting. You don't do anything fancy. That comes later. Keeping the patient alive long enough to be ultimately repaired is the goal. Anyway, we had a lively discussion of scenarios and possible means of repair. He had a lot of war stories to tell, and I can appreciate the need to work within your abilities and resources.
As for my cancer patient from the day before, they pulled out 550 cc of fluid from her lung, and it looked much improved on chest x-ray today. If you remember the bottles from some of my prior entries, it would be a 1/2 liter; about the amount of one of those bottles. She still has some fluid there and will probably need that tapped at some later time.
Sunday, January 27, 2008
Slammin' Saturday Night
If I was complaining about the day before, I am sorry. Mostly because we paid for it last night. We honestly had a 4 - 5 hour wait on non-urgent cases. At one point we had the helicoptor crew, 2 ambulance crews and a list of patients, all urgent, that needed to be transferred. And, this was at the START of the evening. Everything else that came afterward was just icing on an already too full cake.
Oh yeah, did I mention that it was snowing all over Buffalo and on my way to work?
So let's see what I remember from the blur:
- pelvis fracture from sledding with her daughter - she was bleeding into her pelvis and ended up being the patient airlifted to ECMC. The snow had lifted to the point the helicopter could fly out and in.
- 2 strokes that came in back to back - the first was taken by ground transport to MFGates which is the regional stroke center and the second ended up being more minor and was admitted to our facility
- the, almost now routine, I'm having a brain bleed oh yeah AND a heart attack, they were transported by ground to the nearest cardiac center
...and those were just some of the patients I personally didn't see. As for mine. I can't remember all of them but these are the highlights and some generalizations:
- if your teeth are bad and rotting and you've had pain for over a week, Saturday night is not a good night to come to the E.D. and then tell us that you just couldn't wait until Monday to see the dentist and you want something for the pain now. I'm going to stick a big needle into your gums which is going to hurt - a lot - it's going to numb the pain for a couple of hours so you can go home and smoke and drink some more until the Lortabs you demanded kick in. Oh yeah, lady bleeding into pelvis trumps your pain so stop yelling.
- I guess if you get to the point you get lung cancer from smoking and now you're on chemo and you can't remember the names of your medications because you're in almost complete denial about your condition you should just keep smoking. Not going to hurt now and it's the one pleasure you have left, right? I do have sympathy for the fact that you can't breathe and are having a hard time catching your breath. It gives me a chance to stick big needles in your chest and drain out the fluid caused by the cancer which is continuing to grow. The patient was admitted because actually the "fluid" we though we saw on x-ray is probably her cancer getting bigger and taking over one side of her chest. I'll follow up on the CT scan tonight when I get there.
- I am sorry that you had to wait 4 hours to have your bloody nose looked at, but since it stopped that means that it probably wasn't that serious. You don't see it that way and continued to wait despite the fact your nose wasn't bleeding any more. I am sorry I couldn't do anything for you, but again, if the bleeding has stopped... other than look in your nose and make sure there isn't more bleeding... what else would you like me to do? I'm sorry...?
- Some patients win the "Patience" award, like the gentleman who got a thorn in his leg and waited patiently for 6 hours before I could get him into a room to wash-out his wound and make sure there wasn't still a piece of thorn stuck in there. There wasn't, and he went home still smiling, still pleasant.
- Stitches on another gentleman who kept me in stitches while I repaired a pretty decent-sized laceration on his finger. He had also been waiting about 3 hours but kept his sense of humor about him.
- A bounceback from earlier, a patient with a known pulmonary embolism and DVT with worsening shortness of breath. They were going to go into the CT scanner when I left at 5 this morning.
- Kids with cough. They only had to wait about an hour or so because they came in around 11 p.m. when we were finally cleaning up from all the drama earlier in the evening.
- And finally, my 300 + pound patient who noticed about a 40 pound weight gain in a month. He's volume overloaded from his kidney disease, heart disease, and now he is having a hard time breathing from the weight of his belly. He's also developing cellulitis from the pressure and fluid in his legs. We stuck a catheter in his bladder and gave him some lasix which is a diuretic (removes fluid by making you pee). He was admitted.
Whew...! Those are the patients I remember. I am sure there were more, and these were just the patients I saw. They don't include the patients my attending saw, or the PA saw before he left.
I'm heading out the door... we'll see what tonight brings!
Oh yeah, did I mention that it was snowing all over Buffalo and on my way to work?
So let's see what I remember from the blur:
- pelvis fracture from sledding with her daughter - she was bleeding into her pelvis and ended up being the patient airlifted to ECMC. The snow had lifted to the point the helicopter could fly out and in.
- 2 strokes that came in back to back - the first was taken by ground transport to MFGates which is the regional stroke center and the second ended up being more minor and was admitted to our facility
- the, almost now routine, I'm having a brain bleed oh yeah AND a heart attack, they were transported by ground to the nearest cardiac center
...and those were just some of the patients I personally didn't see. As for mine. I can't remember all of them but these are the highlights and some generalizations:
- if your teeth are bad and rotting and you've had pain for over a week, Saturday night is not a good night to come to the E.D. and then tell us that you just couldn't wait until Monday to see the dentist and you want something for the pain now. I'm going to stick a big needle into your gums which is going to hurt - a lot - it's going to numb the pain for a couple of hours so you can go home and smoke and drink some more until the Lortabs you demanded kick in. Oh yeah, lady bleeding into pelvis trumps your pain so stop yelling.
- I guess if you get to the point you get lung cancer from smoking and now you're on chemo and you can't remember the names of your medications because you're in almost complete denial about your condition you should just keep smoking. Not going to hurt now and it's the one pleasure you have left, right? I do have sympathy for the fact that you can't breathe and are having a hard time catching your breath. It gives me a chance to stick big needles in your chest and drain out the fluid caused by the cancer which is continuing to grow. The patient was admitted because actually the "fluid" we though we saw on x-ray is probably her cancer getting bigger and taking over one side of her chest. I'll follow up on the CT scan tonight when I get there.
- I am sorry that you had to wait 4 hours to have your bloody nose looked at, but since it stopped that means that it probably wasn't that serious. You don't see it that way and continued to wait despite the fact your nose wasn't bleeding any more. I am sorry I couldn't do anything for you, but again, if the bleeding has stopped... other than look in your nose and make sure there isn't more bleeding... what else would you like me to do? I'm sorry...?
- Some patients win the "Patience" award, like the gentleman who got a thorn in his leg and waited patiently for 6 hours before I could get him into a room to wash-out his wound and make sure there wasn't still a piece of thorn stuck in there. There wasn't, and he went home still smiling, still pleasant.
- Stitches on another gentleman who kept me in stitches while I repaired a pretty decent-sized laceration on his finger. He had also been waiting about 3 hours but kept his sense of humor about him.
- A bounceback from earlier, a patient with a known pulmonary embolism and DVT with worsening shortness of breath. They were going to go into the CT scanner when I left at 5 this morning.
- Kids with cough. They only had to wait about an hour or so because they came in around 11 p.m. when we were finally cleaning up from all the drama earlier in the evening.
- And finally, my 300 + pound patient who noticed about a 40 pound weight gain in a month. He's volume overloaded from his kidney disease, heart disease, and now he is having a hard time breathing from the weight of his belly. He's also developing cellulitis from the pressure and fluid in his legs. We stuck a catheter in his bladder and gave him some lasix which is a diuretic (removes fluid by making you pee). He was admitted.
Whew...! Those are the patients I remember. I am sure there were more, and these were just the patients I saw. They don't include the patients my attending saw, or the PA saw before he left.
I'm heading out the door... we'll see what tonight brings!
Saturday, January 26, 2008
The Night of Water Torture
It was a looong night.
I didn't write about Thursday night because I only saw 4 patients, and they weren't that interesting. Again, little odd and end things that should have been seen in their own doctor's office. Of course, I did have a group of unruly teenagers who were out "jumpin fences" at 11 p.m. and one girl got hit in the face by a flying elbow. Five sutures across her eyelid which took me less than ten minutes but which had been preceded by 45 minutes of drama. That was about the excitement of the night.
That and the fact I haven't been in a Denny's after hours since before med school, and I decided to stop on my way home yesterday morning since, for some unknown reason, I was craving steak and eggs at 4 in the morning. There was a boisterous crowd for a Thursday night, and the steak was cooked just right. Ah, memories of youth.
But, I digress. Last night was torturous. Not only because of the types of patients we were seeing, but because instead of coming en masse, they showed up as one about every 30 minutes. All night long. It really is torture. You think you've finished up on your last patient and then there's a new one. You're almost ready to discharge that one, and another appears. And, as I said, they appeared almost like clockwork: every 30 minutes.
Last night's sampling brought us:
- a young girl who we were sure had appendicitis, and then her CT scan came back negative. We're still not convinced, so she's coming back tonight for a re-check
- a tragic young woman who has spina bifida (spine didn't completely fuse at birth, usually in just one spot) and has undergone multiple surgeries to help stabilize her spine. Unfortunately, her most recent surgery a year ago lead to complications and a wound infection with MRSA (which you've been hearing so much about in the news), and she had been through a year of debilitating illness and was on the edge of a nervous breakdown. She's facing another surgery and has no emotional support from her significant other or her family. My attending was making arrangements for further care when I left.
- guy with a toothache that said he couldn't get in to see a dentist for 2 more weeks and the pain meds he had been prescribed 2 days prior from the E.D. weren't working. If you know 800 mg of motrin will work for you and you have a prescription for 600 mg, why don't you just add 200 more of regular strength? Seriously, there is no magic formula in the pills that are 800 mg. It's all the same stuff. Really. He didn't agree and left in a huff.
- guy in a snowmobile accident. Apparently there is a huge snowmobile enthusiast population where I am working right now. He was riding and tried to avoid crashing into another machine, but he only ended up hitting the other machine sideways. His ankle was caught in between and now he has a fracture (break) of one of his ankle bones. Splint for him and a referral to ortho.
- and, my idol, a 75 year old woman who still cuts her own wood, drives her own tractor, uses a snow blower on her driveway and still drives. She lost 5 pounds because she was researching her BMI "on the internet" and found out that she was 5 pounds above the recommended weight limit for her age and size. She thought her blood pressure was too high so she came in to get it checked out. She ended up staying with us for several hours longer while we made sure she wasn't having some heart problems and kept her on the monitor. I'll find out what happened when I go back tonight. But, I want to be her when I am that age.
Back for more tonight. I keep hearing rumors of College night Saturday night, so we'll see if they're true.
I didn't write about Thursday night because I only saw 4 patients, and they weren't that interesting. Again, little odd and end things that should have been seen in their own doctor's office. Of course, I did have a group of unruly teenagers who were out "jumpin fences" at 11 p.m. and one girl got hit in the face by a flying elbow. Five sutures across her eyelid which took me less than ten minutes but which had been preceded by 45 minutes of drama. That was about the excitement of the night.
That and the fact I haven't been in a Denny's after hours since before med school, and I decided to stop on my way home yesterday morning since, for some unknown reason, I was craving steak and eggs at 4 in the morning. There was a boisterous crowd for a Thursday night, and the steak was cooked just right. Ah, memories of youth.
But, I digress. Last night was torturous. Not only because of the types of patients we were seeing, but because instead of coming en masse, they showed up as one about every 30 minutes. All night long. It really is torture. You think you've finished up on your last patient and then there's a new one. You're almost ready to discharge that one, and another appears. And, as I said, they appeared almost like clockwork: every 30 minutes.
Last night's sampling brought us:
- a young girl who we were sure had appendicitis, and then her CT scan came back negative. We're still not convinced, so she's coming back tonight for a re-check
- a tragic young woman who has spina bifida (spine didn't completely fuse at birth, usually in just one spot) and has undergone multiple surgeries to help stabilize her spine. Unfortunately, her most recent surgery a year ago lead to complications and a wound infection with MRSA (which you've been hearing so much about in the news), and she had been through a year of debilitating illness and was on the edge of a nervous breakdown. She's facing another surgery and has no emotional support from her significant other or her family. My attending was making arrangements for further care when I left.
- guy with a toothache that said he couldn't get in to see a dentist for 2 more weeks and the pain meds he had been prescribed 2 days prior from the E.D. weren't working. If you know 800 mg of motrin will work for you and you have a prescription for 600 mg, why don't you just add 200 more of regular strength? Seriously, there is no magic formula in the pills that are 800 mg. It's all the same stuff. Really. He didn't agree and left in a huff.
- guy in a snowmobile accident. Apparently there is a huge snowmobile enthusiast population where I am working right now. He was riding and tried to avoid crashing into another machine, but he only ended up hitting the other machine sideways. His ankle was caught in between and now he has a fracture (break) of one of his ankle bones. Splint for him and a referral to ortho.
- and, my idol, a 75 year old woman who still cuts her own wood, drives her own tractor, uses a snow blower on her driveway and still drives. She lost 5 pounds because she was researching her BMI "on the internet" and found out that she was 5 pounds above the recommended weight limit for her age and size. She thought her blood pressure was too high so she came in to get it checked out. She ended up staying with us for several hours longer while we made sure she wasn't having some heart problems and kept her on the monitor. I'll find out what happened when I go back tonight. But, I want to be her when I am that age.
Back for more tonight. I keep hearing rumors of College night Saturday night, so we'll see if they're true.
Thursday, January 24, 2008
Community Photo Challenge - Hometown
Hometown to me has always been the town square, especially in a downtown metro setting, and at night when it's quiet and everything seems magical.
I couldn't decide between the two because I love photos in black & white, so I am putting both.
I couldn't decide between the two because I love photos in black & white, so I am putting both.
Wednesday, January 23, 2008
The Night Life
It's been a real pain trying to adjust to the night shift. I didn't write about my first night shift Monday night since I got in Tuesday morning and went right to bed. Then evening came, and I was trying to stay awake and failed, which didn't matter since I had to get up early this morning to go to Wednesday Grand Rounds. Suffice it to say I was lazy then tired, then it just didn't seem relevant.
I think I only saw about 6 patients Monday night, and they were all follow-ups or issues that should have been handled in their PMD's office during regular hours. However, I was told by one patient who came in with 3 days of fevers that the earliest she could get into her PMD's office would be in 2 weeks. She had a pretty good case of strep throat, and I didn't feel bad about writing her a script for pain meds and antibiotics. Having been through it before, I could understand how miserable she must be feeling.
We cleared the E.D. by about 1:30 in the morning, and I didn't see my next patient until 5 in the morning when I was just about to walk out the door. I stayed to write them up and get things going for my attending and then drove home. I have to admit. I am a morning person. I love bringing in the new day. One of my favorite times is being on the road just as the sun is rising. There's something so perfect in that moment. The world is suddenly full of possibilities. Things to do, things to see, adventures to start.
Of course, I then come home and crash into the bed for about 10 hours of sleep. But the thought is there... You just can't concentrate buried under warm blankets, piled on by 25 pounds of warm kitties...
I'll stay up most of tonight/this morning. Keep the internal clock set to "Vampire." We'll see what my next shift has to bring as the weekend fun begins...
I think I only saw about 6 patients Monday night, and they were all follow-ups or issues that should have been handled in their PMD's office during regular hours. However, I was told by one patient who came in with 3 days of fevers that the earliest she could get into her PMD's office would be in 2 weeks. She had a pretty good case of strep throat, and I didn't feel bad about writing her a script for pain meds and antibiotics. Having been through it before, I could understand how miserable she must be feeling.
We cleared the E.D. by about 1:30 in the morning, and I didn't see my next patient until 5 in the morning when I was just about to walk out the door. I stayed to write them up and get things going for my attending and then drove home. I have to admit. I am a morning person. I love bringing in the new day. One of my favorite times is being on the road just as the sun is rising. There's something so perfect in that moment. The world is suddenly full of possibilities. Things to do, things to see, adventures to start.
Of course, I then come home and crash into the bed for about 10 hours of sleep. But the thought is there... You just can't concentrate buried under warm blankets, piled on by 25 pounds of warm kitties...
I'll stay up most of tonight/this morning. Keep the internal clock set to "Vampire." We'll see what my next shift has to bring as the weekend fun begins...
Sunday, January 20, 2008
Going into Vampire Mode
I haven't written since I've had the last couple of days off, and I was just too tired on Friday after another super busy day in the E.D. At one point, we had 6 charts waiting to be seen and ambulances kept arriving with even more critical patients that would have to be seen first.
I was seeing patients at 4 in the afternoon that had been triaged (assigned level of severity) around 11:30 that morning. Part of the problem, and something I am sure is going on around the country, is that issues that would normally be handled in a primary care office setting were being sent to us. I must have talked to 5 or 6 patients, that when I asked why they came into the E.D. with their problem replied, "I called my primary medical doctor (PMD) who told me they were booked and to go to the E.D."
On a couple of those, my attending and I looked at each other and went, "and what are we supposed to do with this...?" For example, we had two patients who came in complaining of breast pain. One thought she felt a lump, and the other thought she had drainage from one of her nipples. Unless they had an abscess that needed to be drained, which neither did, we wouldn't do much other than refer them back to their PMD to follow-up with a mammogram.
These patients tie up our time from more serious patients, like the man having a heart attack, the young boy with the severe asthma attack or my LOL NAD who fell face forward and needed almost a trauma work-up since she managed to injure herself pretty well. Also, it took me almost 2 hours to put sutures in another patient because I kept getting pulled to other rooms.
Nurses don't get enough credit sometimes. We were so busy that the nurses were preemptively putting in orders, so that on a few of the later patients all I did was basically walk into the room and be ready to discharge or admit the patient on the spot given I had labs and/or films already done.
I stayed late to help clean up a bit. When I left, there were only 2 more patients waiting to be seen, and no one waiting in chairs. Starting tomorrow night I work the night shift, so I will be staying up as late as I can tonight and then taking a nap tomorrow as I try to adjust my clock to vampire mode.
We'll see what the night brings to this some-what sleepy little town...
I was seeing patients at 4 in the afternoon that had been triaged (assigned level of severity) around 11:30 that morning. Part of the problem, and something I am sure is going on around the country, is that issues that would normally be handled in a primary care office setting were being sent to us. I must have talked to 5 or 6 patients, that when I asked why they came into the E.D. with their problem replied, "I called my primary medical doctor (PMD) who told me they were booked and to go to the E.D."
On a couple of those, my attending and I looked at each other and went, "and what are we supposed to do with this...?" For example, we had two patients who came in complaining of breast pain. One thought she felt a lump, and the other thought she had drainage from one of her nipples. Unless they had an abscess that needed to be drained, which neither did, we wouldn't do much other than refer them back to their PMD to follow-up with a mammogram.
These patients tie up our time from more serious patients, like the man having a heart attack, the young boy with the severe asthma attack or my LOL NAD who fell face forward and needed almost a trauma work-up since she managed to injure herself pretty well. Also, it took me almost 2 hours to put sutures in another patient because I kept getting pulled to other rooms.
Nurses don't get enough credit sometimes. We were so busy that the nurses were preemptively putting in orders, so that on a few of the later patients all I did was basically walk into the room and be ready to discharge or admit the patient on the spot given I had labs and/or films already done.
I stayed late to help clean up a bit. When I left, there were only 2 more patients waiting to be seen, and no one waiting in chairs. Starting tomorrow night I work the night shift, so I will be staying up as late as I can tonight and then taking a nap tomorrow as I try to adjust my clock to vampire mode.
We'll see what the night brings to this some-what sleepy little town...
Thursday, January 17, 2008
A Winter's Poupourri
I don't know what was in the air today, but we were hit and hit hard in the late morning hours. We had steady business from 7 to about 10 and then the flood gates just opened. During the barrage, I looked at the clock and ran to the cafeteria around 1230 because I was starving. I finished my wrap around 3 in the afternoon because I was only able to take about a bite every 1/2 hour because we were so busy. I think the next time I was able to sit and think it was around 4 p.m.
These are the cases I saw, which are only about a third of the patients seen since my attending and the PA were also frantically running from room to room. These do not include the massive heart attack who, by the way, was also bleeding into his brain(transfer to ICU at one of the regional heart hospitals that also has neurosurgery); the patient with the infected leg (ala my trucker from a few days ago) who was septic with a blood pressure into the low 60's (admit to the ICU); the man with the chicken bone caught in his throat from the night before (he came in today because he wasn't able to swallow his breakfast, now he's going to surgery); and several sprains I heard about in passing.
My patients:
Admission for joint infection: don't get drunk and then into fights with your foster son. And, Lord 'o mercy, if you're going to, don't hit him in the mouth. The human mouth has the nastiest of bacteria in it, and especially if you're a diabetic your hand is going to get infected, badly. He was going to the OR with ortho surgery to get a "wash out." It means opening up the wound and scrubbing all the badness you can out of it.
Generalized weakness: LOL NAD from the local nursing home who wouldn't wake up this morning, but who was fine and alert by the time EMS arrived, and even moreso by the time she arrived in the E.D. Still, we had to do a work-up to make sure she wasn't just extra sleepy this morning. Back to nursing home for her after all her tests came back negative.
Pharyngitis: HIV+ patients aren't normal in many senses. They can't have a "simple cough." You always have to be thinking about the 100's of rare and opportunistic infections they might have picked up. Luckily, this patient has a simple sore throat. Still, antibiotics for a few days.
Knee strain: Electricians have a hazardous job. I thought their only worry was getting shocked, but it seems those "cherry pickers" they work in are also a health hazard. Especially if they don't get lowered to the ground gently. My patient wasn't and was now having knee pain. In essence, it's like falling from 6 - 8 feet and landing on your feet. You get the jar and the shock of the fall, only the machine adds a bit of acceleration. They'll need an MRI with their ortho follow-up.
Transfer to outside facility for subdural hematoma (brain bleed): This patient came in complaining of having several days of nausea and vomiting and now feeling week. They'd taken a couple of falls, but they denied hitting their head. After several hours, lots of fluid and a full work-up for their vomiting, we tried to stand them up. They fell over. So we got a CAT scan even though their neurological exam was completely normal. Surprise, they had a massive bleed in their head. "Oh, yeah, Doc. I guess I did hit my head with that last fall last night." Obviously, I didn't do a complete memory exam. They're going to the region's stroke center for a neurosurgery consult.
Admit to ICU for hemoptysis (coughing up blood): When I was a 4th year medical student, I got to put in my first chest tube. As an intern in surgery, I put in 13 during my first 5 weeks as a doctor. I've done many more since then, and other than central lines, I think it's one of the procedures I really enjoy doing. However, not on little old ladies with lung cancer who came in "for a simple biopsy" and ended up with a collapsed lung and bleeding into their chest. It's a known complication of a lung biopsy, but if you're that 1 in 100 who has the complication, it's no picnic.
She was intubated (I tried but missed), and then I got the chest tube in. She had lung cancer on one side, and the biopsy and damage was to the other lung where a new lesion was seen. So it affected the one good lung she had. She went to the ICU. I don't know that she'll make it. I'll check in on her tomorrow if she survives the night.
Abdominal pain (still waiting for a CAT scan when I left, so I'll get the results tomorrow and see what happened to them.)
Upper respiratory infection: my token pedi patient. I might be getting better since I didn't make her scream when I looked in her ears. Either that or she was too sick to care. She gets rest and fluids.
Hyperemesis gravidum: you're pregnant and you get REALLY bad morning sickness that lasts all day and night. This was her 3rd visit to the E.D. in as many weeks for dehydration. None of her labs were abnormal, so she got fluid ("tanked up") and anti-nausea drugs. She'll follow-up with her primary doc next week.
Whew! That's it. One more day and then I have the weekend off. We'll see what rolls in the door tomorrow....
These are the cases I saw, which are only about a third of the patients seen since my attending and the PA were also frantically running from room to room. These do not include the massive heart attack who, by the way, was also bleeding into his brain(transfer to ICU at one of the regional heart hospitals that also has neurosurgery); the patient with the infected leg (ala my trucker from a few days ago) who was septic with a blood pressure into the low 60's (admit to the ICU); the man with the chicken bone caught in his throat from the night before (he came in today because he wasn't able to swallow his breakfast, now he's going to surgery); and several sprains I heard about in passing.
My patients:
Admission for joint infection: don't get drunk and then into fights with your foster son. And, Lord 'o mercy, if you're going to, don't hit him in the mouth. The human mouth has the nastiest of bacteria in it, and especially if you're a diabetic your hand is going to get infected, badly. He was going to the OR with ortho surgery to get a "wash out." It means opening up the wound and scrubbing all the badness you can out of it.
Generalized weakness: LOL NAD from the local nursing home who wouldn't wake up this morning, but who was fine and alert by the time EMS arrived, and even moreso by the time she arrived in the E.D. Still, we had to do a work-up to make sure she wasn't just extra sleepy this morning. Back to nursing home for her after all her tests came back negative.
Pharyngitis: HIV+ patients aren't normal in many senses. They can't have a "simple cough." You always have to be thinking about the 100's of rare and opportunistic infections they might have picked up. Luckily, this patient has a simple sore throat. Still, antibiotics for a few days.
Knee strain: Electricians have a hazardous job. I thought their only worry was getting shocked, but it seems those "cherry pickers" they work in are also a health hazard. Especially if they don't get lowered to the ground gently. My patient wasn't and was now having knee pain. In essence, it's like falling from 6 - 8 feet and landing on your feet. You get the jar and the shock of the fall, only the machine adds a bit of acceleration. They'll need an MRI with their ortho follow-up.
Transfer to outside facility for subdural hematoma (brain bleed): This patient came in complaining of having several days of nausea and vomiting and now feeling week. They'd taken a couple of falls, but they denied hitting their head. After several hours, lots of fluid and a full work-up for their vomiting, we tried to stand them up. They fell over. So we got a CAT scan even though their neurological exam was completely normal. Surprise, they had a massive bleed in their head. "Oh, yeah, Doc. I guess I did hit my head with that last fall last night." Obviously, I didn't do a complete memory exam. They're going to the region's stroke center for a neurosurgery consult.
Admit to ICU for hemoptysis (coughing up blood): When I was a 4th year medical student, I got to put in my first chest tube. As an intern in surgery, I put in 13 during my first 5 weeks as a doctor. I've done many more since then, and other than central lines, I think it's one of the procedures I really enjoy doing. However, not on little old ladies with lung cancer who came in "for a simple biopsy" and ended up with a collapsed lung and bleeding into their chest. It's a known complication of a lung biopsy, but if you're that 1 in 100 who has the complication, it's no picnic.
She was intubated (I tried but missed), and then I got the chest tube in. She had lung cancer on one side, and the biopsy and damage was to the other lung where a new lesion was seen. So it affected the one good lung she had. She went to the ICU. I don't know that she'll make it. I'll check in on her tomorrow if she survives the night.
Abdominal pain (still waiting for a CAT scan when I left, so I'll get the results tomorrow and see what happened to them.)
Upper respiratory infection: my token pedi patient. I might be getting better since I didn't make her scream when I looked in her ears. Either that or she was too sick to care. She gets rest and fluids.
Hyperemesis gravidum: you're pregnant and you get REALLY bad morning sickness that lasts all day and night. This was her 3rd visit to the E.D. in as many weeks for dehydration. None of her labs were abnormal, so she got fluid ("tanked up") and anti-nausea drugs. She'll follow-up with her primary doc next week.
Whew! That's it. One more day and then I have the weekend off. We'll see what rolls in the door tomorrow....
Tuesday, January 15, 2008
Neither Rain, nor Snow, nor...
I almost thought I wasn't going to make it into work this morning. Going on the Thruway I hit a wall of snow and at certain points I couldn't even see the road ahead and had to drive about 10 mph. I know a couple of times I felt the "sleeper strip" on the right side of the road when I actually thought I was right in the middle of the road.
The voices you hear are from "Fox and Friends" on the Fox News Channel which I listen to on my satellite radio.
But, I made it. My attending must have only a few minutes behind me, because when I got to the hospital the overnight attending told me the day attending was going to be about 30 minutes late. Since we'd come through the same patch of snow, she must have assumed like I did that it was that way all the way down, but it wasn't. She arrived about 5 minutes after I did.
Today was more of an "Urgent Care" kind of day. Little nicks and scratches. Nothing really urgent. We had 3 patients that were very sick requiring admission, but for the most part everything else was bread and butter ED stuff. At least I got a tutorial of sorts on orthopedic injuries, and I got to keep my sewing skills up to date placing many sutures.
In order:
Finger lac from opening the plastic wrap around a memory stick with scissors: clean and steri strip
Hand lac from a slipping off the end of a wrench: clean and suture and feel just a little glad at the pain I inflicted to this real jerk of a patient, just a little glad...
Abdominal pain: didn't actually find anything wrong with him except I had to dig his one remaining testicle out of his groin. And, that wasn't the source of his pain. Go figure. We called him Abdominal Pain of Unknown Etiology (cause) and told him to come back if he had any more pain
Wrist strain: glove got caught in a drill at work and twisted his hand inside the glove, ouch!
Minor shoulder separation: fell on his shoulder after getting tackled while playing football. This is why there should be snow on the ground to cushion the fall. Ground is frozen up nice and hard at this time of year.
Pneumonia: this was one of the admissions. Couldn't keep her oxygenation above 90% with minimal oxygen, so she gets admitted.
Wound check: a guy I saw 2 days ago came in to have his abscess drainage wound checked. I gave him the ok to go on with his life and not have to return to the E.D.
Wrist strain: a teen and something called "Animal Ball" which you play indoors and involves dribbling, volleyballs and a soccer net. My patient was the goalie who managed to block the shot but injured his wrist in the process.
Face lac: college cheerleader got hit in the face by the elbow of one of her teammates. Her biggest concern was that she couldn't make the trip to compete in the National Cheerleading Competition. You might have seen it on ESPN2. I have. They're not a big name school, but they compete nonetheless. She'll be able to go. Just hope the stitching job won't be too noticeable. I put in the smallest sutures I could find: 6-0.
Finger lac: couldn't sew this one. A cook cut the edge of the tip of his finger right off. Nothing to put back together, and he thought the missing piece might be mixed in with the bacon he was cutting for a salad. Don't worry, you won't be finding his finger in your Caesar Salad. The whole batch of bacon got thrown out.
That's it. Tomorrow is Grand Rounds so meetings all morning and no work for me. Which is a good thing as I have a TON of things to do...
The voices you hear are from "Fox and Friends" on the Fox News Channel which I listen to on my satellite radio.
But, I made it. My attending must have only a few minutes behind me, because when I got to the hospital the overnight attending told me the day attending was going to be about 30 minutes late. Since we'd come through the same patch of snow, she must have assumed like I did that it was that way all the way down, but it wasn't. She arrived about 5 minutes after I did.
Today was more of an "Urgent Care" kind of day. Little nicks and scratches. Nothing really urgent. We had 3 patients that were very sick requiring admission, but for the most part everything else was bread and butter ED stuff. At least I got a tutorial of sorts on orthopedic injuries, and I got to keep my sewing skills up to date placing many sutures.
In order:
Finger lac from opening the plastic wrap around a memory stick with scissors: clean and steri strip
Hand lac from a slipping off the end of a wrench: clean and suture and feel just a little glad at the pain I inflicted to this real jerk of a patient, just a little glad...
Abdominal pain: didn't actually find anything wrong with him except I had to dig his one remaining testicle out of his groin. And, that wasn't the source of his pain. Go figure. We called him Abdominal Pain of Unknown Etiology (cause) and told him to come back if he had any more pain
Wrist strain: glove got caught in a drill at work and twisted his hand inside the glove, ouch!
Minor shoulder separation: fell on his shoulder after getting tackled while playing football. This is why there should be snow on the ground to cushion the fall. Ground is frozen up nice and hard at this time of year.
Pneumonia: this was one of the admissions. Couldn't keep her oxygenation above 90% with minimal oxygen, so she gets admitted.
Wound check: a guy I saw 2 days ago came in to have his abscess drainage wound checked. I gave him the ok to go on with his life and not have to return to the E.D.
Wrist strain: a teen and something called "Animal Ball" which you play indoors and involves dribbling, volleyballs and a soccer net. My patient was the goalie who managed to block the shot but injured his wrist in the process.
Face lac: college cheerleader got hit in the face by the elbow of one of her teammates. Her biggest concern was that she couldn't make the trip to compete in the National Cheerleading Competition. You might have seen it on ESPN2. I have. They're not a big name school, but they compete nonetheless. She'll be able to go. Just hope the stitching job won't be too noticeable. I put in the smallest sutures I could find: 6-0.
Finger lac: couldn't sew this one. A cook cut the edge of the tip of his finger right off. Nothing to put back together, and he thought the missing piece might be mixed in with the bacon he was cutting for a salad. Don't worry, you won't be finding his finger in your Caesar Salad. The whole batch of bacon got thrown out.
That's it. Tomorrow is Grand Rounds so meetings all morning and no work for me. Which is a good thing as I have a TON of things to do...
Sunday, January 13, 2008
Fading Fast
I am shredded after getting up at 5 every morning so I can be on the road by 6 to make it to work by 7 and then driving the hour home after my 10 hours of work, so I will only be posting one story today.
Truck drivers are a hardy lot. I like to drive, but I can't imagine being alone for days at a time traveling from place to place. Luckily my patient today had a dispatcher that was watching out for him when his "oh, it's just a scratch" turned into something potentially more deadly.
His dispatcher called the local sheriff after directing the driver to a parking lot for the night. The next morning she didn't think he sounded quite right, so that's when she called local authorities. EMS found him confused and with the following injury:
He had fallen just after New Year's and never got the injury checked out. Now he's got a raging infection, kidney failure, and the real possibility of losing his limb. We got him re-hydrated, and he began to make some more sense. He'll be admitted to the CCU for several days I am sure. I had to call the sheriff's office to make sure to secure his big rig.
I'll have to admit, I really enjoyed this patient. Once his confusion began to clear, he had us all laughing with his personality. He was one of the interesting cases in a day of interesting cases. But, I will write more tomorrow as I am going to bed early and sleeping in... oh yeah. Me and the kitties in a big pile on the bed.
Truck drivers are a hardy lot. I like to drive, but I can't imagine being alone for days at a time traveling from place to place. Luckily my patient today had a dispatcher that was watching out for him when his "oh, it's just a scratch" turned into something potentially more deadly.
His dispatcher called the local sheriff after directing the driver to a parking lot for the night. The next morning she didn't think he sounded quite right, so that's when she called local authorities. EMS found him confused and with the following injury:
He had fallen just after New Year's and never got the injury checked out. Now he's got a raging infection, kidney failure, and the real possibility of losing his limb. We got him re-hydrated, and he began to make some more sense. He'll be admitted to the CCU for several days I am sure. I had to call the sheriff's office to make sure to secure his big rig.
I'll have to admit, I really enjoyed this patient. Once his confusion began to clear, he had us all laughing with his personality. He was one of the interesting cases in a day of interesting cases. But, I will write more tomorrow as I am going to bed early and sleeping in... oh yeah. Me and the kitties in a big pile on the bed.
Saturday, January 12, 2008
EFD - Exam from Doorway
When I was a medical student, I did orthopedic surgery as my surgical sub-internship. Rounds on patients consisted of little more than an assessment of peripheral pulses and a glance at the INR (measure of coagulation) to determine that evening's warfarin dose. Stable patients received an EFD - Exam from doorway. Just a peek in, make a diagnosis and off you go. Today kind of reminded me of that.
I had a new attending today. It was quite a trip. We had a not-so-busy-morning, and he would send me to see every patient that came in. That was no big deal, but it was interesting to see that he almost always had the discharge paperwork ready before I even presented the patient to him... We did real well keeping patients coming in and out until about lunch time, then suddenly 3 ambulances and a somewhat critical patient all arrived around the same time.
The diagnoses today:
- contact dermatitis: yep, even in winter, poison ivy plants are around. To keep in mind: men who scratch everywhere get rashes wherever they scratch. WHEREVER they scratch. Just had to smile and move on...
- fractured PICC line: my theory continues to be, if you have metastatic cancer of any kind, in this case renal cell carcinoma with metastases to bone, you can have anything you want. One of the bummers is having your central line crack and leak causing you discomfort. We pulled the line, and they will come in on Monday to have it replaced.
- eye laceration: I actually don't see a lot of mentally challenged patients. This one came from a local group home. He has a condition that makes him wheelchair bound and spastic. So spastic he whacked his head on the side of the bath when he was being washed and had a cut. It's the first time I've had to apply glue to a wound on a moving target. I got the edges together. Not my best job, but it will do the trick.
- otitis media: Moms who have sick kids can end up getting sick too. Three small children at home all with colds. Mom finally made it in and has an ear infection. Some antibiotics will help her medically.
- bronchitis: Some of the drugs that best help can also hurt. My patient had a heart attack several months back and is on blood thinners for his stent and heart. He's been coughing a lot and today came in because he had coughed up 2 large clots of blood. We made sure he didn't have anything else going on, and then I lectured him on the hazards of smoking because his lungs were starting to look like Swiss cheese on his CAT scan. He might listen... might.
- pneumonia: When we decide to order tests and studies, it's based on clinical suspicion. Words like crushing chest pain, non-mobile and one-sided swelling trigger thoughts of DVT's and PE's. Many labs, a CAT scan and thoughts of anti-coagulants later, they had pneumonia. Antibiotics and try to get out of bed every once in a while.
- COPD exacerbation: stop smoking when you're 20, seriously, I don't want to see you every week in the ED because you've been smoking for 40 years and are on home oxygen and your breathing is getting worse. I can't fix what's already broke. All I can do is a quick patch until the next time.
- medication refill: It must really suck to be 27 and have been in and out of the hospital since you were a teen. This patient already had a kidney transplant (which failed and they're back on dialysis) and bilateral (both-sided) hip replacements, one side with a revision. He has chronic pain. His doctor was out of town, and he's out of pain meds... supposedly, but hey, like the cancer patient, he'll pretty much get what ever he wants.
- possible medication ingestion: How a 2 year old can find his granddad's medication, open the bottles despite child-proofing and manage to pour all of the pills out onto the floor is the beginning of a near tragedy. Sis turned around "for just a second" and he managed to do all this. So, we watched him. Most of the medication might make him sleepy or sick to his stomach, and he was doing fine in the ED and didn't appear to have actually tried any of the pills, but still. You can't just send them home. They have to sit, for at least 6 hours.
and finally - anorexia: We joke about little old ladies and their tea and toast diets, but they get anemic. Then they get tired, and what little they used to eat they don't any more. Then they get more sick and tired and eat less, and you get where I'm going. Plus, I think there was an element of depression here. Husband died 2 years ago. Lives alone. I talked to her and her daughter about some possible solutions, so we'll see.
One more shift and then I have a day off... so it's off to bed for me. Until tomorrow.
I had a new attending today. It was quite a trip. We had a not-so-busy-morning, and he would send me to see every patient that came in. That was no big deal, but it was interesting to see that he almost always had the discharge paperwork ready before I even presented the patient to him... We did real well keeping patients coming in and out until about lunch time, then suddenly 3 ambulances and a somewhat critical patient all arrived around the same time.
The diagnoses today:
- contact dermatitis: yep, even in winter, poison ivy plants are around. To keep in mind: men who scratch everywhere get rashes wherever they scratch. WHEREVER they scratch. Just had to smile and move on...
- fractured PICC line: my theory continues to be, if you have metastatic cancer of any kind, in this case renal cell carcinoma with metastases to bone, you can have anything you want. One of the bummers is having your central line crack and leak causing you discomfort. We pulled the line, and they will come in on Monday to have it replaced.
- eye laceration: I actually don't see a lot of mentally challenged patients. This one came from a local group home. He has a condition that makes him wheelchair bound and spastic. So spastic he whacked his head on the side of the bath when he was being washed and had a cut. It's the first time I've had to apply glue to a wound on a moving target. I got the edges together. Not my best job, but it will do the trick.
- otitis media: Moms who have sick kids can end up getting sick too. Three small children at home all with colds. Mom finally made it in and has an ear infection. Some antibiotics will help her medically.
- bronchitis: Some of the drugs that best help can also hurt. My patient had a heart attack several months back and is on blood thinners for his stent and heart. He's been coughing a lot and today came in because he had coughed up 2 large clots of blood. We made sure he didn't have anything else going on, and then I lectured him on the hazards of smoking because his lungs were starting to look like Swiss cheese on his CAT scan. He might listen... might.
- pneumonia: When we decide to order tests and studies, it's based on clinical suspicion. Words like crushing chest pain, non-mobile and one-sided swelling trigger thoughts of DVT's and PE's. Many labs, a CAT scan and thoughts of anti-coagulants later, they had pneumonia. Antibiotics and try to get out of bed every once in a while.
- COPD exacerbation: stop smoking when you're 20, seriously, I don't want to see you every week in the ED because you've been smoking for 40 years and are on home oxygen and your breathing is getting worse. I can't fix what's already broke. All I can do is a quick patch until the next time.
- medication refill: It must really suck to be 27 and have been in and out of the hospital since you were a teen. This patient already had a kidney transplant (which failed and they're back on dialysis) and bilateral (both-sided) hip replacements, one side with a revision. He has chronic pain. His doctor was out of town, and he's out of pain meds... supposedly, but hey, like the cancer patient, he'll pretty much get what ever he wants.
- possible medication ingestion: How a 2 year old can find his granddad's medication, open the bottles despite child-proofing and manage to pour all of the pills out onto the floor is the beginning of a near tragedy. Sis turned around "for just a second" and he managed to do all this. So, we watched him. Most of the medication might make him sleepy or sick to his stomach, and he was doing fine in the ED and didn't appear to have actually tried any of the pills, but still. You can't just send them home. They have to sit, for at least 6 hours.
and finally - anorexia: We joke about little old ladies and their tea and toast diets, but they get anemic. Then they get tired, and what little they used to eat they don't any more. Then they get more sick and tired and eat less, and you get where I'm going. Plus, I think there was an element of depression here. Husband died 2 years ago. Lives alone. I talked to her and her daughter about some possible solutions, so we'll see.
One more shift and then I have a day off... so it's off to bed for me. Until tomorrow.
Friday, January 11, 2008
Not Meant to Be
We had a steady stream of work today. One of the cases that affected me most was a 22 year old coming in, 17 weeks' pregnant and spotting. We'd actually had a patient earlier in the morning come in who was in the middle of miscarrying. She had hoped the baby might be saved, but ultrasound showed she'd already lost it.
My patient basically broke her waters around midnight last night. When I put the ultrasound probe on her, I could see very little fetal movement even though the heart was still beating. We did a pelvic (yes, ick, that's right), and we found that her cervix was at 1cm open. She got admitted and will probably be passing the fetus some time tonight. She was very sad.
Otherwise, a mishmosh of this and that, mostly things that can be taken care of in a primary physician's office, but when your doctor has a full schedule and can't get you in today, you come to the E.D. Or, when you don't like the care your doctor gave you, you come to the E.D. for a quick fix, even though it's something your primary care doctor should have taken care of.
My patients today...
Back pain man - I've had chronic back pain for year then fell at work a week ago and my doctor gave me pain meds but they're not helping and I want you to make me better.
Tattoo man - I don't care what kind of bet you make with your buddies when you're 20, when they ask you to tattoo women's clothing on your body and you do it, there's something just wrong there. (I would have loved to have taken a photo, but a surgery resident just lost their job for photographing a patient's privates that were specially tattooed, on a bet mind you.)
Seizure lady - softball-size brain tumor removed 17 years ago and as a consequence has seizures. Found in her car in the parking lot of a store after she ran over a curb and came to a stop.
PROM (premature rupture of membranes) girl - the one I mentioned before. Admitted to OB/gyn.
Rule out MI lady - sent in from her doctor's office after complaining of being dizzy and having been found to have low blood pressure. Her complaint to us was of chest pain, so we had to admit her to evaluate for an MI (heart attack.) Very nice lady; she's had 11 children. Ouch.
Pneumonia lady - Another patient sent from their doctor's office for a lowO2 saturation (82%). She had pneumonia and was being admitted.
Sore throat lady - just got that tickle feeling in the back of the throat and wanted to get it checked out. Cultures sent and she was sent out the door.
No pedi's today (pedi's = children, as in pediatrics).
Back to work over the weekend. We'll see what's stirring up!
My patient basically broke her waters around midnight last night. When I put the ultrasound probe on her, I could see very little fetal movement even though the heart was still beating. We did a pelvic (yes, ick, that's right), and we found that her cervix was at 1cm open. She got admitted and will probably be passing the fetus some time tonight. She was very sad.
Otherwise, a mishmosh of this and that, mostly things that can be taken care of in a primary physician's office, but when your doctor has a full schedule and can't get you in today, you come to the E.D. Or, when you don't like the care your doctor gave you, you come to the E.D. for a quick fix, even though it's something your primary care doctor should have taken care of.
My patients today...
Back pain man - I've had chronic back pain for year then fell at work a week ago and my doctor gave me pain meds but they're not helping and I want you to make me better.
Tattoo man - I don't care what kind of bet you make with your buddies when you're 20, when they ask you to tattoo women's clothing on your body and you do it, there's something just wrong there. (I would have loved to have taken a photo, but a surgery resident just lost their job for photographing a patient's privates that were specially tattooed, on a bet mind you.)
Seizure lady - softball-size brain tumor removed 17 years ago and as a consequence has seizures. Found in her car in the parking lot of a store after she ran over a curb and came to a stop.
PROM (premature rupture of membranes) girl - the one I mentioned before. Admitted to OB/gyn.
Rule out MI lady - sent in from her doctor's office after complaining of being dizzy and having been found to have low blood pressure. Her complaint to us was of chest pain, so we had to admit her to evaluate for an MI (heart attack.) Very nice lady; she's had 11 children. Ouch.
Pneumonia lady - Another patient sent from their doctor's office for a lowO2 saturation (82%). She had pneumonia and was being admitted.
Sore throat lady - just got that tickle feeling in the back of the throat and wanted to get it checked out. Cultures sent and she was sent out the door.
No pedi's today (pedi's = children, as in pediatrics).
Back to work over the weekend. We'll see what's stirring up!
Thursday, January 10, 2008
Strange Weather We're Having
This is what weather in Buffalo, at least to most people's minds, is supposed to be like during the winter. However, the storm system I videotaped on my way to work last week which dumped a bunch of snow has now passed, and all the snow is gone. It sort of feels like spring, but way too early. I know there's more snow coming... I think. At least, I hope! I had planned to go snowboarding on days off because this is my light month.
Regardless of the weather, a strange phenomenon happened in the E.D. today... what if there was an Emergency Department and nobody came? That's about right. At most, we had 2 patients on the board at any one time. I think this morning we might have had 3, but for the most part, just 2, mostly 1.
My patients were unexciting by most means:
"I have a cough and cold and just can't go into work today" - prescription for gaifenesin and a work note
"I have a cough, I don't know why I'm here" - LOLNAD (Little Old Lady in No Apparent Distress, refer to prior posts) sent from nursing home for near syncope (she almost passed out.) Nothing apparently cardiac, but she got admitted for unsteadiness on her feet and a UTI (urinary tract infection)
"I can't sleep because I feel really short of breath" - congestive heart failure exacerbation (worsening) he gets admitted to be "tuned up." His concern was the $287 he was going to have to pay for an overnight stay in the hospital that his insurance didn't cover.
"My son has a temp and has been pulling at his ears." - another chance to play pediatrician. He had some fluid behind one ear drum. Most likely a chronic collection, but we drew a white count (if it's elevated it could signal an infection.) It came back normal, and the child was doing better. Home with instructions for follow-up. Most cases will get better on their own; no need for antibiotics.
"I can't pee and I feel like I have to go all the time." - used my ultrasound skills, and the patient did not have a distended bladder. Urine showed infection, so some antibiotics and off you go...
And, seriously, that was it for my 10 hour shift. We did also have about 3 other patients that I didn't see. Again, nothing real exciting, but the weekend's coming up and the weather's supposed to be turning nasty once again. Pray for big white fluffy snow.
Tuesday, January 8, 2008
Does the sun shine in Buffalo?
Ok, so this morning I got up extra early for a shower before my hour's drive to my new rotation: ED in a small, 9 bed community hospital. The sky was dark all the way to work. When I left at around 5:30 p.m., the sky was dark all the way home. Luckily, I have a lot of days off, so I am sure I will see the sun at some point.
So, new hospital and learning a new system and getting used to new attendings, etc. I found out today that most of the patients have most of the same complaints. However, small town life can be a bit more colorful at times, and patients here have a tendency to be frequent fliers. I also like being back in a position of having everything I need brought to me.
When I was a house doc working at the community hospital, whatever I needed was immediately retrieved and brought to the bedside. There was even a situation where I was called to a patient's bedside for SVT (it's a very fast rhythm) in the middle of the night. My mouth was so dry, and gross (ew, morning breath at 2 a.m. is not fun) that all I wanted was a piece of gum. I related such to the nursing supervisor that came to every call with the Rapid Response team. A few minutes later a floor nurse came up and asked if I was the House Doctor. I said, "yes," and she handed me several sticks of gum that had been tubed to the nurses' station. Now that's service!
But, I digress. The nurses indeed were very friendly and happy to set up eye kits, ENT kits, and, ughhh, pelvic setups, when asked. Orders magically disappeared and were entered expeditiously, and the ED hummed along.
I saw about 8 patients today. We suddenly got very busy about the time I was leaving so I had to sign out a couple of my more interesting cases.
There was:
Bartender who got hit in the eye with a spitball. Take these eyedrops and consider safety goggles at work. - corneal abrasion
Mr. Elderly man with knee pain for over 20 years that still hurts. "What are you going to do to make it better?" MRI shows a lesion on the end of his thigh bone. Looks like cancer. Dude, you get any drug you want from me. From my attending, not so much. We advanced his ortho appointment by a few days and gave him a little something for the ride home to help his pain. For now.
Bipolar, borderline personality with depression lady who came in complaining of chest pain after being on the road for 2 days. No DVT and no heart attack that I could tell on prelims. She'll probably be let loose to continue her way home to New England. - most likely some sort of panic attack
I'm-pregnant-with-child-number-nine (yes, nine)-at-age-29 (that's right)-and-I-have-belly-pain. My ultrasound skills showed a happy bouncing baby swimming in a sea of amniotic fluid. Poor kid doesn't know what's waiting on the other side. Mom's smoking, of course. ("I cut down to just 6 or 7 a day.") Ugghh, pelvic with gross everything. Doesn't look like a miscarriage, and I will have to check her cultures. Most likely some pelvic inflammation.
Recovering drug addict sent from clinic for high blood pressure. He'd had nothing to eat but a piece of toast and some coffee... His usual 5 - 6 cups. Plus his cigarettes. Around a pack and a half a day. After walking a half mile to the appointment and climbing stairs I'd look a little ragged too. Sent him right back out as his blood pressure was normal on two readings, and he had no other symptoms.
Lady with weird groin pain "going down into my leg." Couldn't see anything on ultrasound, but she had a lump. She was being wheeled to CT as I was leaving so I will have to find out what happens later.
And, finally, just fresh off the cardiac care unit service, I got a "I had chest pains yesterday, but I didn't want to come in, and today my wife made me and now I have EKG changes." He's being worked up for an MI, and I signed him out as well, so I'll have to see what happens to him.
That's it. Tomorrow is Wonderful Wednesday with Grand Rounds and no work for me....
So, new hospital and learning a new system and getting used to new attendings, etc. I found out today that most of the patients have most of the same complaints. However, small town life can be a bit more colorful at times, and patients here have a tendency to be frequent fliers. I also like being back in a position of having everything I need brought to me.
When I was a house doc working at the community hospital, whatever I needed was immediately retrieved and brought to the bedside. There was even a situation where I was called to a patient's bedside for SVT (it's a very fast rhythm) in the middle of the night. My mouth was so dry, and gross (ew, morning breath at 2 a.m. is not fun) that all I wanted was a piece of gum. I related such to the nursing supervisor that came to every call with the Rapid Response team. A few minutes later a floor nurse came up and asked if I was the House Doctor. I said, "yes," and she handed me several sticks of gum that had been tubed to the nurses' station. Now that's service!
But, I digress. The nurses indeed were very friendly and happy to set up eye kits, ENT kits, and, ughhh, pelvic setups, when asked. Orders magically disappeared and were entered expeditiously, and the ED hummed along.
I saw about 8 patients today. We suddenly got very busy about the time I was leaving so I had to sign out a couple of my more interesting cases.
There was:
Bartender who got hit in the eye with a spitball. Take these eyedrops and consider safety goggles at work. - corneal abrasion
Mr. Elderly man with knee pain for over 20 years that still hurts. "What are you going to do to make it better?" MRI shows a lesion on the end of his thigh bone. Looks like cancer. Dude, you get any drug you want from me. From my attending, not so much. We advanced his ortho appointment by a few days and gave him a little something for the ride home to help his pain. For now.
Bipolar, borderline personality with depression lady who came in complaining of chest pain after being on the road for 2 days. No DVT and no heart attack that I could tell on prelims. She'll probably be let loose to continue her way home to New England. - most likely some sort of panic attack
I'm-pregnant-with-child-number-nine (yes, nine)-at-age-29 (that's right)-and-I-have-belly-pain. My ultrasound skills showed a happy bouncing baby swimming in a sea of amniotic fluid. Poor kid doesn't know what's waiting on the other side. Mom's smoking, of course. ("I cut down to just 6 or 7 a day.") Ugghh, pelvic with gross everything. Doesn't look like a miscarriage, and I will have to check her cultures. Most likely some pelvic inflammation.
Recovering drug addict sent from clinic for high blood pressure. He'd had nothing to eat but a piece of toast and some coffee... His usual 5 - 6 cups. Plus his cigarettes. Around a pack and a half a day. After walking a half mile to the appointment and climbing stairs I'd look a little ragged too. Sent him right back out as his blood pressure was normal on two readings, and he had no other symptoms.
Lady with weird groin pain "going down into my leg." Couldn't see anything on ultrasound, but she had a lump. She was being wheeled to CT as I was leaving so I will have to find out what happens later.
And, finally, just fresh off the cardiac care unit service, I got a "I had chest pains yesterday, but I didn't want to come in, and today my wife made me and now I have EKG changes." He's being worked up for an MI, and I signed him out as well, so I'll have to see what happens to him.
That's it. Tomorrow is Wonderful Wednesday with Grand Rounds and no work for me....
Friday, January 4, 2008
Doing the CCUing Out the Door Dance
1100 (T - 0) My patients are all signed out and my shift is over. I am heading home for some rest after doing a few errands. The next time you see me I will be starting my rotation (not until Tuesday!!!) at one of the local community hospitals, and I will be back in the E.D. So for now, good night, and good luck!
0700 (T - 4h) 24 hours later and I am pre-rounding for my patients again. Getting their information. A little behind due to the admission.. oh, I should get back to it!
0600 (T - 5h) My resident paged me. The perfect night is ruined. Got an admission in the E.D. I can't complain. I wonder what number my colleague is on.
0515 (T-5.45h) I got a page from the same nurse for the "I need a sleeping pill patient" for some lab orders and a Foley (urine catheter.) I mumbled "yes" in my sleep and rolled over again.
0200 (T - 9h) I just came back from another Code Blue. This time, a patient that had coded on the floor during the prior code had been transferred down to the MICU. He had just come down and within about 1/2 hour he was bradying down (heart rate was slowing: bradycardia = heart beat less than 50.) I went upstairs to find them doing CPR and he had just been intubated. He was the 6th admission for my fellow EM resident, and, when the patient was pronounced, she came out to tell me she was expecting her 7th admission. I keep waiting for the pager to go off. (It did once but only to ask if a patient could have a sleeping pill. Sure, why not?) For now, it's back to dreaming about city streets and neighborhood layouts. Maybe, I've been playing SimCity too much. Hmm.
23:15 (T - 11.75h) So, for the last 4 hours since my last entry, I have been watching television in our resident room. I saw all of a CSI episode, followed by most of the movie "Working Girl," and then I channel surfed for a while. I was just about to get extra comfortable in the recliner when I heard a Code called overhead. A Code Blue is cardiac or respiratory arrest, meaning the patient's heart isn't beating or they're not breathing, or both. Although, they called a Code Blue this afternoon only to find the patient was actually just sleeping. Must have been a young nurse or aide. Anyway, I went upstairs to find one of my fellow EM residents there and a crowd in the room. Initially, the story was that the patient was found down on the floor in their bathroom. Then we noticed the makeshift noose made out of a hospital gown hanging from the shower rod. Apparently a nurse's aide went in to check on the patient and found him hanging. He'd been taken off the telemetry monitor just a minute or so earlier, so he hadn't been there long. We stabilized his neck and moved him to the bed where he was intubated. He became more responsive and had started to breath on his own prior to having the tube put in, but for his own safety he was intubated. We have to worry about neck fractures and any damage he might have done to his trachea. Also, how much brain he might have damaged, although little if the timing is correct. He'll be going to the MICU (Medical Intensive Care Unit) tonight. The EM resident working there will probably be able to tell us what happens with him in the morning. She's on her 5th admission of the night. I, myself, am planning to settle in my comfy recliner and hope the white cloud keeps blocking out the admissions.
1900 (T - 16h) We had dinner. It was a nice beef souvlaki salad for me. Currently on the low-carb/no-carb diet for the next 6 weeks until the wedding. My patient who's now re-intubated seems to be doing well. By my read, CT scan looks negative for anything scary. His heart, lungs, kidneys and liver still have a ways to go. We got a new patient. Another 4 - 5 beer a day, plus I smoke and sometimes do drugs, kinda guy. He's going to be a pain just because, as I've stated before, chronic drug users (ie: heroin, cocaine, etc.) tend to fry out their pain receptors and then usually need more medication to help them with something you or I might take an ibuprofen for. I am getting ready to relax for a bit and pray my white cloud keeps me covered over night. (Residents, especially surgeons, believe you're either a white cloud - nothing happens when you're on call or it's a light call, or black clouds - chaos rules and you get many admissions.) I had a friend who I used to call a black cloud with thunderstorm warnings because whenever he took call it seemed the service was suddenly three times as busy. Here's to praying for blue skies all around me...
1545 (T - 19.25h) Just got back from running downstairs because a patient had self-extubated (pulled out their own breathing tube.) I admitted this gentleman yesterday. (Getting on the soapbox) Everyone should learn CPR. My patient was at home and told his wife that he felt like he was having heartburn. Then he suddenly shuddered and collapsed. She called to him and then called EMS. Their response time was about 5 - 6 minutes, but meanwhile nothing was done for this patient. When they arrived, he was in v-fib arrest (let me just say this is bad) and needed to be shocked twice. They got his heart going again, and when he came to he suddenly became very agitated and combatative. So much so that they needed to put a breathing tube in when he arrived to the E.D. We pulled the tube out yesterday because he was responding to voice and following commands. He was again very combatative and not breathing properly so he needed to be put back on the ventilator. Today, we had sent him downstairs for a CT scan to check out his brain, and he somehow managed to reach up and pull out his breathing tube despite being in restraints. When I was a medical student at the VA, this meant the patient was ready to be extubated (have the breathing tube removed) but in this case, not so much. So, now he's reintubated, and I am going to go see what his CT scan shows.
We got another admission which means the evening resident will be leaving, and I will be responsible for all admissions until morning. We're in the process of ordering dinner. Yes, it's early, but you never know when you're going to eat on-call, so it's better to have cold food than no food at 11 p.m. if you're suddenly busy. The day continues...
1230 (T - 22.5h) At lunch. Admitted a patient this morning: needs by-pass surgery for bad coronary artery disease, but oh, by the way, is a Jehovah's Witness so no blood products, and on peritoneal dialysis for bad kidneys, AND had a severe allergic reaction to anesthesia. Oh yeah, if you know you have clogged coronaries don't wait several hours for your son to come home before going to the hospital, go when you're having the chest pain. Every minute is another 1000 heart cells lost. And, to add to the on-going drama in the CCU (more on that at some other point), the I'm-having-a-heart-attack-again-yet-continue-to-smoke-and-hate-waiting-in-ED's decided he didn't like the No Smoking policy and left. I think I talked about signing out AMA (against medical advice) once before. He did. He was warned he could drop dead. He didn't care. He was warned not to drive because he's driven off the road once already. He didn't care. Probably was lighting up as he was walking across the lobby and out the door...
0915 (T - 25.75h) - So, rounds just ended, and they weren't too bad. What's bad is the story of one of the patients admitted overnight. They started to have chest pain two days ago around 8 p.m., so instead of going to the hospital, they thought it was more important to drive to get kerosene to heat their house. On the way, they became dizzy and light-headed and drove their car off the road. Around midnight, they were found by local PD and thought to be inebriated because they were confused. So, they were arrested and taken to the local jail. When the breathalizer was negative and a friend who was an officer recognized them, they were released. By the way, they continued to have chest pain. So, their fiancee came and picked them up and took them home. The next morning they went to see their primary doctor who did an EKG and told the patient to go straight to the emergency department. (Me, I would have called EMS, but that's just me.) According to the patient, they were ignored for 30 minutes despite complaining of chest pain, shortness of breath and diaphoresis (sweating.) So, they left. And came to BGH yesterday evening where they were admitted and are now on our service. Yep, they've had a heart attack. Don't feel too bad for them. They continue to smoke 3, yes 3, packs a day of cigarettes like they have for the last 30 years despite having had 9 heart attacks, a 4 vessel by-pass, and a very strong family history of heart attacks before the age of 40 including deaths on both sides of the family. Natural selection, folks. More to come I am sure...
0730 (T-27.5h) - I got to the hospital about 1/2 hour ago. I brought coffee and donut holes (Dunkin, ooh gourmet compared to the "Timmy's" everyone here seems to like). I like to show my appreciation to the staff. I've done it since I splurged as an intern and bought pizzas for 2 shifts at Cook County for the floor 8 nurses. They REALLY helped me get used to new environs and work around the system. Anyway, I've collected all the data from last night (vitals, labs, medications) and now I am off to physically examine my patients before rounds...
0700 (T - 4h) 24 hours later and I am pre-rounding for my patients again. Getting their information. A little behind due to the admission.. oh, I should get back to it!
0600 (T - 5h) My resident paged me. The perfect night is ruined. Got an admission in the E.D. I can't complain. I wonder what number my colleague is on.
0515 (T-5.45h) I got a page from the same nurse for the "I need a sleeping pill patient" for some lab orders and a Foley (urine catheter.) I mumbled "yes" in my sleep and rolled over again.
0200 (T - 9h) I just came back from another Code Blue. This time, a patient that had coded on the floor during the prior code had been transferred down to the MICU. He had just come down and within about 1/2 hour he was bradying down (heart rate was slowing: bradycardia = heart beat less than 50.) I went upstairs to find them doing CPR and he had just been intubated. He was the 6th admission for my fellow EM resident, and, when the patient was pronounced, she came out to tell me she was expecting her 7th admission. I keep waiting for the pager to go off. (It did once but only to ask if a patient could have a sleeping pill. Sure, why not?) For now, it's back to dreaming about city streets and neighborhood layouts. Maybe, I've been playing SimCity too much. Hmm.
23:15 (T - 11.75h) So, for the last 4 hours since my last entry, I have been watching television in our resident room. I saw all of a CSI episode, followed by most of the movie "Working Girl," and then I channel surfed for a while. I was just about to get extra comfortable in the recliner when I heard a Code called overhead. A Code Blue is cardiac or respiratory arrest, meaning the patient's heart isn't beating or they're not breathing, or both. Although, they called a Code Blue this afternoon only to find the patient was actually just sleeping. Must have been a young nurse or aide. Anyway, I went upstairs to find one of my fellow EM residents there and a crowd in the room. Initially, the story was that the patient was found down on the floor in their bathroom. Then we noticed the makeshift noose made out of a hospital gown hanging from the shower rod. Apparently a nurse's aide went in to check on the patient and found him hanging. He'd been taken off the telemetry monitor just a minute or so earlier, so he hadn't been there long. We stabilized his neck and moved him to the bed where he was intubated. He became more responsive and had started to breath on his own prior to having the tube put in, but for his own safety he was intubated. We have to worry about neck fractures and any damage he might have done to his trachea. Also, how much brain he might have damaged, although little if the timing is correct. He'll be going to the MICU (Medical Intensive Care Unit) tonight. The EM resident working there will probably be able to tell us what happens with him in the morning. She's on her 5th admission of the night. I, myself, am planning to settle in my comfy recliner and hope the white cloud keeps blocking out the admissions.
1900 (T - 16h) We had dinner. It was a nice beef souvlaki salad for me. Currently on the low-carb/no-carb diet for the next 6 weeks until the wedding. My patient who's now re-intubated seems to be doing well. By my read, CT scan looks negative for anything scary. His heart, lungs, kidneys and liver still have a ways to go. We got a new patient. Another 4 - 5 beer a day, plus I smoke and sometimes do drugs, kinda guy. He's going to be a pain just because, as I've stated before, chronic drug users (ie: heroin, cocaine, etc.) tend to fry out their pain receptors and then usually need more medication to help them with something you or I might take an ibuprofen for. I am getting ready to relax for a bit and pray my white cloud keeps me covered over night. (Residents, especially surgeons, believe you're either a white cloud - nothing happens when you're on call or it's a light call, or black clouds - chaos rules and you get many admissions.) I had a friend who I used to call a black cloud with thunderstorm warnings because whenever he took call it seemed the service was suddenly three times as busy. Here's to praying for blue skies all around me...
1545 (T - 19.25h) Just got back from running downstairs because a patient had self-extubated (pulled out their own breathing tube.) I admitted this gentleman yesterday. (Getting on the soapbox) Everyone should learn CPR. My patient was at home and told his wife that he felt like he was having heartburn. Then he suddenly shuddered and collapsed. She called to him and then called EMS. Their response time was about 5 - 6 minutes, but meanwhile nothing was done for this patient. When they arrived, he was in v-fib arrest (let me just say this is bad) and needed to be shocked twice. They got his heart going again, and when he came to he suddenly became very agitated and combatative. So much so that they needed to put a breathing tube in when he arrived to the E.D. We pulled the tube out yesterday because he was responding to voice and following commands. He was again very combatative and not breathing properly so he needed to be put back on the ventilator. Today, we had sent him downstairs for a CT scan to check out his brain, and he somehow managed to reach up and pull out his breathing tube despite being in restraints. When I was a medical student at the VA, this meant the patient was ready to be extubated (have the breathing tube removed) but in this case, not so much. So, now he's reintubated, and I am going to go see what his CT scan shows.
We got another admission which means the evening resident will be leaving, and I will be responsible for all admissions until morning. We're in the process of ordering dinner. Yes, it's early, but you never know when you're going to eat on-call, so it's better to have cold food than no food at 11 p.m. if you're suddenly busy. The day continues...
1230 (T - 22.5h) At lunch. Admitted a patient this morning: needs by-pass surgery for bad coronary artery disease, but oh, by the way, is a Jehovah's Witness so no blood products, and on peritoneal dialysis for bad kidneys, AND had a severe allergic reaction to anesthesia. Oh yeah, if you know you have clogged coronaries don't wait several hours for your son to come home before going to the hospital, go when you're having the chest pain. Every minute is another 1000 heart cells lost. And, to add to the on-going drama in the CCU (more on that at some other point), the I'm-having-a-heart-attack-again-yet-continue-to-smoke-and-hate-waiting-in-ED's decided he didn't like the No Smoking policy and left. I think I talked about signing out AMA (against medical advice) once before. He did. He was warned he could drop dead. He didn't care. He was warned not to drive because he's driven off the road once already. He didn't care. Probably was lighting up as he was walking across the lobby and out the door...
0915 (T - 25.75h) - So, rounds just ended, and they weren't too bad. What's bad is the story of one of the patients admitted overnight. They started to have chest pain two days ago around 8 p.m., so instead of going to the hospital, they thought it was more important to drive to get kerosene to heat their house. On the way, they became dizzy and light-headed and drove their car off the road. Around midnight, they were found by local PD and thought to be inebriated because they were confused. So, they were arrested and taken to the local jail. When the breathalizer was negative and a friend who was an officer recognized them, they were released. By the way, they continued to have chest pain. So, their fiancee came and picked them up and took them home. The next morning they went to see their primary doctor who did an EKG and told the patient to go straight to the emergency department. (Me, I would have called EMS, but that's just me.) According to the patient, they were ignored for 30 minutes despite complaining of chest pain, shortness of breath and diaphoresis (sweating.) So, they left. And came to BGH yesterday evening where they were admitted and are now on our service. Yep, they've had a heart attack. Don't feel too bad for them. They continue to smoke 3, yes 3, packs a day of cigarettes like they have for the last 30 years despite having had 9 heart attacks, a 4 vessel by-pass, and a very strong family history of heart attacks before the age of 40 including deaths on both sides of the family. Natural selection, folks. More to come I am sure...
0730 (T-27.5h) - I got to the hospital about 1/2 hour ago. I brought coffee and donut holes (Dunkin, ooh gourmet compared to the "Timmy's" everyone here seems to like). I like to show my appreciation to the staff. I've done it since I splurged as an intern and bought pizzas for 2 shifts at Cook County for the floor 8 nurses. They REALLY helped me get used to new environs and work around the system. Anyway, I've collected all the data from last night (vitals, labs, medications) and now I am off to physically examine my patients before rounds...
Thursday, January 3, 2008
Tomorrow's a Big Day
Well, tomorrow is it. The end of the CCU rotation. My goal is to do a play by play during call. We'll see how that works out. As for today, we did a little cleaning house. Moved most of our patients out of the unit and onto the floors upstairs. And, most of my patients went to private services... meaning off my service, and I don't have to do the discharge dictation...!
So, until tomorrow for a Friday night on call...
CCU Countdown:Days until the end of the rotation: 3
Actual number of days I will be working during that time: 2
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off: 2 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0
Number of long call shifts remaining: 1 - TOMORROW!!!
Number of patients: 2 - I picked up a new one from yesterday
Number of evil nurses in the unit: 4 - evil nursing aide actually made #4, she just had too much attitude for one small person
Number of evil Internal Medicine residents: 2
So, until tomorrow for a Friday night on call...
CCU Countdown:Days until the end of the rotation: 3
Actual number of days I will be working during that time: 2
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off: 2 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0
Number of long call shifts remaining: 1 - TOMORROW!!!
Number of patients: 2 - I picked up a new one from yesterday
Number of evil nurses in the unit: 4 - evil nursing aide actually made #4, she just had too much attitude for one small person
Number of evil Internal Medicine residents: 2
Wednesday, January 2, 2008
Last CCU Short Call
So this is my first official entry of 2008. I didn't write on New Year's Day because after an exceptionally long morning of rounds for a non-workday, I decided to take a nap. After waking up just long enough to have dinner, feed the cats and get things organized for another day of work, I just decided to go to bed.
One interesting thing that happened yesterday is that the patient who was brain dead died. I spent another hour with the son the day prior and had finally gotten him to the point of thinking in terms of finding a funeral home and thinking about his parent's last wishes. Then, he suddenly changed his mind again and said that something else could probably be done for his parent, and that as long as they were on the breathing tube, he could still come and see them.
I then told him that if his parent's heart stopped, it was no longer a matter of choice. They would be removed from the ventilator, and he would have to tell the hospital where to send his parent for burial. Again, I am usually very kind and understanding when it comes to talking to families about their loved ones, their conditions, and in talking to families about witholding or removing care. But, this situation called for me to be more brusk and candid than I usually am. I felt bad about this. I really like to be as understanding and patient with families as I can be, but that wasn't going to be the case in this situation.
When I came in yesterday morning for rounds, the patient's temperature had dropped to the low 90's, and the nurses were having a hard time getting a blood pressure. When the patient's heart rate dropped to the 30's, we knew we were close. When the patient went asystole (flat-lined), we ran the code, gently, and then pronounced the patient.
I called the son to let him know his parent had died, and he would now need to make arrangements. At that point, he finally seemed to have an acceptance of what had happened and came to the hospital to say good-bye. The social worker promised to help him out with whatever he needed. So that was the start of his New Year, and too, I guess, of mine.
CCU Countdown:Days until the end of the rotation: 4
Actual number of days I will be working during that time: 3
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off: 3 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0 - I finish tonight!
Number of long call shifts remaining: 1
Number of patients: 2
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 2
Tags: CCU, code blue, end of life, health care proxy
One interesting thing that happened yesterday is that the patient who was brain dead died. I spent another hour with the son the day prior and had finally gotten him to the point of thinking in terms of finding a funeral home and thinking about his parent's last wishes. Then, he suddenly changed his mind again and said that something else could probably be done for his parent, and that as long as they were on the breathing tube, he could still come and see them.
I then told him that if his parent's heart stopped, it was no longer a matter of choice. They would be removed from the ventilator, and he would have to tell the hospital where to send his parent for burial. Again, I am usually very kind and understanding when it comes to talking to families about their loved ones, their conditions, and in talking to families about witholding or removing care. But, this situation called for me to be more brusk and candid than I usually am. I felt bad about this. I really like to be as understanding and patient with families as I can be, but that wasn't going to be the case in this situation.
When I came in yesterday morning for rounds, the patient's temperature had dropped to the low 90's, and the nurses were having a hard time getting a blood pressure. When the patient's heart rate dropped to the 30's, we knew we were close. When the patient went asystole (flat-lined), we ran the code, gently, and then pronounced the patient.
I called the son to let him know his parent had died, and he would now need to make arrangements. At that point, he finally seemed to have an acceptance of what had happened and came to the hospital to say good-bye. The social worker promised to help him out with whatever he needed. So that was the start of his New Year, and too, I guess, of mine.
CCU Countdown:Days until the end of the rotation: 4
Actual number of days I will be working during that time: 3
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off: 3 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0 - I finish tonight!
Number of long call shifts remaining: 1
Number of patients: 2
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 2
Tags: CCU, code blue, end of life, health care proxy
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